Oral lichen planus (OLP) is as common as psoriasis and affects
approximately 1-2% of the population. The disease develops in women
more than twice as often as in men and most commonly occurs in the
fifth to sixth decade of life, although the disease can sometimes
affect children.

Recalcitrant cutaneous lupus erythematosus (CLE) causes patients
considerable discomfort and often leads to disfigurement. Although
the majority of CLE responds to the combination of sun protection,
local glucocorticoids, and antimalarials, some cases require more
aggressive therapy.

Clinical Updates

Challenges in Cross-border Clinical Dermatology Training in Asia – The Way Ahead

Introduction

Today, dermatology remains at the cutting edge of medical
science and technology with incredible breakthroughs emerging every
day that give fresh hope to millions of people suffering from the
many incurable skin diseases around the world. Indeed, dermatology
is one of the most dynamic areas of medicine, and over the last few
decades we have seen various subspecialties such as photobiology,
immunodermatopathology, genodermatology and pediatric dermatology
flourish within the larger context of clinical dermatology.

The constant evolution of our specialty has required
dermatologists to courageously embrace new concepts and modify
their care plans as new treatments, such as biologics agents,
become widely available. A conscious effort is needed to maintain a
balanced approach, stay away from commercialization and develop our
professional competence in keeping with best clinical practice that
is being promoted around the world.

Population, economics and diversity in Asia - the challenge of
numbers

Asia has one of the world's most unique geopolitical mixes of
cultures and ethnicity. Economy-wise it is a truly vibrant and
interesting emerging market with the potential to be the world
leader for the next decade. This is evidenced by the arrival of
several global industrial giants, who are beginning to make their
mark in this region. At the same time, it is also home to some of
the world's poorest and most deprived human communities.

Today, Asia's population stands at 3.6 billion and is growing at
the rate of 1.2% per year, inhabiting a land mass of only 25
million square kilometers, compared to Latin America's population
of 550 million in 20 million square kilometers. This is the perfect
recipe for overcrowding, sustained poverty traps and outbreak of
infectious diseases, which are the real challenges for those
wanting to deliver better medical as well as clinical dermatology
services.

Asian populations will continue to grow for many years to come,
increasing pressure on the region's natural and human resources. In
the next 35 years, national populations are predicted to grow in
every country of East, South East, South and Central Asia except
Singapore, Japan and Kazakhstan. Populations will double or nearly
double in Pakistan, Nepal, Bangladesh, Afghanistan, Cambodia, and
Laos. Growth rates will also be particularly high in India,
Indonesia, Iran, Malaysia, Mongolia, Myanmar, the Philippines and
Vietnam.

Much of the population growth projected for the next few decades
will occur in countries that are least capable of coping with
additional stress on land, water, and other natural resources. In
2001, Prescott-Allan released the results of their study where they
showed that the countries where population is projected to grow
fastest have some of the lowest income levels in the world. These
countries already rank high in terms of environmental stress.

It is clear that in a scenario like this, emphasis on
dermatology service provision and development will not be high on
the list of priorities of the politicians, health economists and
policy-makers of most Asian nations. In short, the ball is in our
court.

The task is therefore left to the dermatologist as the
custodians of this discipline to make things work and move under
minimum resources through close networking, sharing of expertise
and seamless clinical dermatology training programs that will be
the platform for future dermatologists. The operational challenge
is to get ideas and programs across borders to countries and to
people speaking completely different languages and practicing in
completely different cultures and political systems. This is our
biggest challenge.

Getting the right business model is important. The commodity we
are talking about is not money but the common desire and drive of
good professionals to share and exchange knowledge and technology
to communities in need.

The challenge of cosmetic dermatology

Closer to heart is the challenge of cosmetic dermatology which
is threatening to engulf members of our fraternity, both young and
old.

The rise of managed care, increasing fragmentation of the field
of dermatology, lower salaries paid to specialists in clinical
dermatology compared to other fields of dermatology, and a lack of
political will in the specialty, have put tremendous pressure on
clinical dermatology in Asia, as in the rest of the world. In
addition, escalating health care costs and the long lag time
between new discoveries in the treatment of skin diseases and the
time it actually reaches patients in Asia, have altered economic
incentives such that it has become increasingly common for
dermatologists to handle a mixture of clinical, surgical and
cosmetic interventions, and in some cases, purely cosmetic
procedures.

Hence we may be seeing the beginning of the end of the day for
the 'purist' clinician in dermatology.

There is no doubt that products and procedures designed to
advance the practice of cosmetic dermatology have flooded our
specialty during the past ten years, and that cosmetic dermatology
will continue to grow in scope and size over the next few decades.
However, while the needs and desires of the consumers will continue
to influence the direction of dermatology, as with other
specialties, we as a medical profession have the responsibility to
safeguard our integrity as healthcare providers.

Today, many newly qualified young Asian dermatologists would
immediately gravitate into the lucrative field of cosmetic
dermatology forsaking the calling of their discipline. Few would
stay to endure the long hours tediously caring for the sick that
genuinely need what we were trained for. We cannot allow a
situation where dermatologists are seen as beauticians, rather than
people who treat the ill. Cosmetic procedures should be grounded in
clinical dermatology, rather than seen as a new subset of our
specialty that represents dermatological practice for the
future.

It is expected that many dermatologists will throw up their
hands in submission and jump onto the ship to the land of lasers,
IPL, Botox, fillers, golden threads, and silver needles. The
challenge is how to turn this ship around.

What makes clinical dermatology special is that it is a dynamic
and practical science. Doctors and patients can virtually see in
real-time their disease getting better or worse day by day. No
other organ or tissue will offer its clinician such a privilege.
The joy of seeing dermatological science display its miracles on
disease skin gives a feeling of satisfaction that money can't buy.
What we need next is to set the benchmarks in clinical dermatology
as a practical science to be enjoyed by all.

In this we have dermatopathology.

Dermatologists in Asia should adopt dermatopathology as the
basic benchmark of good clinical practice in making accurate
dermatological diagnosis. This is a ready tool that we are just not
using enough. Biopsy rates are too low in everyday dermatological
practice here. In many Asian countries, one dermatopathologist
virtually serves the entire country. We do not biopsy because there
is no ready dermatopathologist around. The fact is that, there are
just insufficient dermatopathology services to serve the thousands
of dermatologists, a situation rampant across the region.

This is a major challenge and we must address it. Building a
critical mass of specialized and dedicated dermatopathologists is
one of the priorities that the profession itself can address
without going to the policy-makers and the politicians.

The Asian Academy of Dermatology and Venereology (AADV) have
taken this first step in 2011 to commence the Fellowship Training
program in Clinical Dermatopathology (FAADV). This is a dermatology
subspecialty training program like no other undertaken in any other
part of the world.

The initial support from the regional bodies has been
overwhelming. The first observation is that there is that there has
been great interest from our dermatologists as well as general
pathologists in such programs. Approximately 150 delegates attended
the first basic course held in Kuala Lumpur in October 2011. The
advanced course, attended by a similar number, was held in 2012
(Photograph 1) together with the first FAADV (Dematopathology)
examination in which three candidates passed (Photograph 2). A
second post-basic dermatopathology course and examination is
scheduled for Danang, Vietnam on 09 April 2014 in conjunction with
the 21st Regional Conference of Dermatology
(Asian-Australasian).

Adding clinical and basic science research upon the above, AADV
expects to push Asian dermatology training over the next ten
years.

There are important lessons to be learned from experiences of
the International Society for Investigative Dermatology. Despite
its importance, its international membership component only has 499
members representing 40 countries, of which only Japan and Korea
are among the top five non-English-speaking countries. Even in
Japan, the President of the Japanese Society for Investigative
Dermatology has reported a falling trend in number of younger
dermatologists taking interest in this area of dermatology.
Elsewhere in Asia, there is just little or no interest in
investigative dermatology.

This trend must be arrested, hence the call for the formation of
an Asian Investigative Dermatology Group to stir up interest and
motivate the present and next generation of dermatologists. We need
to call upon the strength in investigative dermatology from our
colleagues in North and South Asia to help leapfrog the rest of
Asia in investigative dermatology.

One priority is to continue to emphasize and promote research
and innovation in the various sub-specialties that make dermatology
a joy to practice. Asia is a treasure stove for basic and clinical
dermatology research. We have boundless clinical material well
beyond what is seen in the Western countries.

First and foremost, it is timely to review research and publish
on clinical epidemiology of skin diseases in Asia. It is also
timely to review this as a whole, and how these diseases are
currently managed and treated in the background of our many
commonly practiced traditional and indigenous treatment
modalities.

We have to harness the effects of the many recent breakthroughs
in our specialty and how these new medications and therapies may or
may not be relevant in our practice here in Asia.

Several key areas will be pivotal to our success in this field
in the next 10-20 years in Asia. The challenge now is to develop
clinical and basic science research, look at new drugs in old
fields and also to relook at older drugs which have been left
behind by the commercial pressure of newer agents There is also
much to be done for systemic biologic agents for treatment of
inflammatory skin diseases, biomedical engineering, stem-cell
therapy, minimally invasive procedural dermatology and
patient-related issues.

In Asia, as in the other continents of the world, clinical
dermatology is being assailed on all fronts by other medical
specialties, a trend that emanated from the developed countries.
Already, in many countries, dermatologists no longer exclusively
handle HIV and sexually transmitted diseases which have drifted
into the province of infectious disease specialists, urologists and
genito-urinary medicine physicians. Many Asian dermatologists
themselves have given up looking at leprosy, TB and other
traditional chronic skin infections. Otolaryngologists, allergists
and immunologists and the like have moved in to claim their ground.
To the rheumatologists treating psoriatic arthritis, cutaneous
manifestations of psoriasis are no longer the key issues when they
see patients. If we do not react, dermatologists may soon find
themselves excluded from providing care for these patients by
insurance companies, third party-payors and managed care
organizations.

With these changes, dermatologists need to realign and
vigorously develop and defend our core territory, otherwise the day
will come where dermatology would really be a minor discipline
whose main concern is the beauty rather than the health of the
skin. By then dermatology would really be just skin-deep. For a
good measure dermatologists should take leadership in
subspecialties like allergy, clinical immunology and cutaneous
oncology, among others, to keep this desire for improvement
burning.

With the march of globalization (The World Trade Organization,
General Agreement on Tariffs and Trade, ASEAN (Association of
Southeast Asian Nations) Free Trade Area, ASEAN Framework Agreement
on Services and the Mutual Recognition Arrangement), Asia and in
particular, South East Asia is becoming increasing borderless with
respect to movement of medical practitioners and services. The day
is already here where a dermatologist from one Asian country can
freely move into a neighboring country to practice, provided they
can fulfil the existing rules of the host country. With this
freedom of movement come the issue of turf-protection and the
standard of training in dermatology and how to harmonize it. There
is often a perception that a dermatologist from country A is never
good enough for your own country B. This may not be really true but
a mindset change is needed.

The fact of the matter is that there may be many different
training systems for dermatologists in the different nations in
Asia. Standards, point of entry, qualification and language of
instruction may differ. Having looked at different system across
Asia, we can confidently say that in dermatology, the basic
approach, curriculum, clinical training and post-graduate
supervision of full-time dermatology trainees are essentially
uniform across the region. Whilst politicians prefer to divide
services, we as professionals should move the other way by
harmonizing and synergizing our strengths across all nations in
Asia.

What is needed is a platform to harmonize the different training
programs that will allow trainees to move across nations to enrich
and expand their experiences seeing and treating skin disease in
different geographical and cultural scenarios. At the end of the
day we shall have a truly qualified professional made in and made
for Asia. A harmonized Clinical Dermatology Fellowship Training
program is the target for the near future.

Conclusion

Together as a fraternity, dermatologists need to find new
strategies to develop clinical dermatology in the context of our
Asian geo-political and socio-economic uniqueness. Programs are
needed to foster fellowship and mutual respect between our fellows
across North and South, East and West Asia. In this context,
regional organization like the AADV can help build bridges to
enhance dermatology knowledge exchange and technology transfer
within Asia. This mutual framework cannot be built with money but
with common political will and commitment.

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